Characteristics of Intracerebral Hemorrhage During Rivaroxaban Treatment

Abstract

N ovel oral anticoagulants (NOACs) reduce incidence of stroke and intracerebral hemorrhage (ICH) in patients with nonvalvular atrial fibrillation.1 Several studies demonstrated hematoma expansion in patients with ICH occurring during warfarin therapy and poor clinical outcomes.2 However, information regarding hematoma size, its expansion, and functional and vital outcomes of patients with ICH occurring during NOAC treatment have been limited and remain largely unclear.Cerebral microbleeds (CMBs) are said to be predictive of the occurrence of ICH or ischemic stroke 3 and to increase the risk of warfarin-associated ICH. 4 Furthermore, a considerable interest has been shown in association between CMBs and subsequent ICH in patients treated with NOACs. 5 In the present study, we investigated clinical and neuroradiological characteristics of patients with ICH occurring during NOAC treatment. MethodsFrom April 2011 through October 2013, 585 patients (342 men) with ICH were admitted to the Hirosaki Stroke and Rehabilitation Center for acute therapy <7 days after the onset (n=329) and for further rehabilitation therapy <60 days after the onset from other hospitals (n=256). Of all, 5 patients (1%) had ICH during NOAC treatment with nonvalvular atrial fibrillation, 56 (10%) during warfarin, and the other 524 (89%) during Background and Purpose-Neuroradiological characteristics and functional outcomes of patients with intracerebral hemorrhage (ICH) during novel oral anticoagulant treatment were not well defined. We examined these in comparison with those during warfarin treatment. Methods-The consecutive 585 patients with ICH admitted from April 2011 through October 2013 were retrospectively studied. Of all, 5 patients (1%) had ICH during rivaroxaban treatment, 56 (10%) during warfarin, and the other 524 (89%) during no anticoagulants. We focused on ICH during rivaroxaban and warfarin treatments and compared the clinical characteristics, neuroradiological findings, and functional outcomes. Results-Patients in the rivaroxaban group were all at high risk for major bleeding with hypertension, abnormal renal/ liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly (HAS-BLED) score of 3 and higher rate of past history of ICH. Moreover, multiple cerebral microbleeds (≥4) were detected more frequently in rivaroxaban group than in warfarin (80% versus 29%; P=0.04). Hematoma volume in rivaroxaban group was markedly smaller than that in warfarin (median: 4 versus 11 mL; P=0.03). No patient in the rivaroxaban group had expansion of hematoma and surgical treatment. Rivaroxaban group showed lower modified Rankin Scale at discharge relative to warfarin, and the difference between modified Rankin Scale before admission and at discharge was smaller in rivaroxaban than in warfarin (median: 1 versus 3; P=0.047). No patient in the rivaroxaban group died during hospitalization, whereas 10 (18%) warfarin patients died. Conclusions-Rivaroxaban-associated ICH occur...

Prognostic Value of Prothrombin Time International Normalized Ratio in Acute Decompensated Heart Failure – A Combined Marker of Hepatic Insufficiency and Hemostatic Abnormality –

“…It is well known that plasma factor VII and complexes of tissue factor/factor VIIa are important initiators of the coagulation cascade, and thus suppression of factor VII by warfarin may lead to increased hemorrhage. 58, 59 We found that a significant number of ADHF patients who were not treated with anticoagulants showed increased INR on admission. Therefore, warfarin should be used carefully during the acute phase of heart failure, although ADHF patients are susceptible to thromboembolism through diuretic use and activated coagulation system.…”

Spontaneous intracranial epidural hematoma during rivaroxaban treatment

“…However, when compared with combined warfarin, the hematomas were smaller, had no expansion, and had favorable functional/survival outcomes. 14 In this context, the once-a-day dosage, the need for monitoring the INR, no inferiority to warfarin in treating the atrial fibrillation, and the decreased risk of bleeding in comparison to warfarin have made rivaroxaban an attractive alternative in patients who plan to use this anticoagulant.…”

“…19 Moreover, multiple cerebral micro bleeds were detected more frequently in the rivaroxaban group than in the warfarin group. 14 These are important data that we take into account in the selection of the patient for the use of the drug. Even in a young patient, as in the case presented and without other risk factors for bleeding, the use of rivaroxaban can be a triggering factor for the intracranial bleeding.…”

Volume and functional outcome of intracerebral hemorrhage according to oral anticoagulant type

“…7,8 Although experimental models show that dabigatran 9 and rivaroxaban 10 -unlike warfarindo not increase ICH volume unless given at supratherapeutic doses, few data are available on the clinical and radiologic characteristics of NOAC-ICH. A small study from Japan recently reported that in 5 patients with ICH associated with the NOAC rivaroxaban, the mean hematoma volume was smaller than in a comparison group of ICH associated with warfarin, 11 and that functional outcomes were better in the NOAC group.…”